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Tue March 12, 2013

A Clinical Dilemma: Prescribing Pot To Patients

This is TALK OF THE NATION. I'm Neal Conan, in Washington. In 18 states and the District of Columbia, marijuana is medicine by popular vote. A lot of doctors don't see it that way. They say pot presents problems that include potency, efficacy, corruption, and of course it's still illegal under federal law.

Others see solutions for symptoms difficult to address any other way, and cases can be very different: a 70-year-old cancer patient suffering with chemo or a 25-year-old with problems going to sleep. So doctors, we want to hear from you today. If medical marijuana is legal where you practice, how do you decide whether or not to prescribe it? Our number is 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, New York Times columnist Tom Friedman on the politics of the Keystone XL pipeline decision. But first, doctors and pot. As part of a series called "Clinical Decisions," the New England Journal of Medicine prompted the discussion on the medical use of marijuana. Two contributors join us now.

Here with us in Studio 3A is Dr. Robert DuPont, the first director of the National Institutes of Drug Abuse, currently with Georgetown's medical school as clinical professor of psychiatry. Good to have you with us today.

ROBERT DUPONT: Glad to be here, thank you.

CONAN: And joining us from a studio at Mayo Clinic in Rochester, Minnesota, is Dr. Michael Bostwick, who teaches in the Department of Psychiatry at the medical school there, and welcome to you.

MICHAEL BOSTWICK: Thank you so much, pleasure to be here.

CONAN: And so what's the first question you ask yourself about whether marijuana might be appropriate for a patient, Dr. Bostwick?

BOSTWICK: Well, I wrote an article about how I thought that this was a very complicated question with no easy answer. And my contention is that the most important thing is the relationship between the doctor and the patient, and further that this is a substance that we can't do proper research on even though we're calling for the need for proper research. So I think we have dilemma after dilemma.

I'm not in a state where we can actually prescribe marijuana, but I became interested in this because I had encountered in my own patient practice, and in my family, folks who said, oh, there's no problem with it, there's nothing wrong with it, it's just a great thing. And even though I wrote the pro position, I actually could have written the con equally as easily.

(LAUGHTER)

CONAN: So a complicated situation.

BOSTWICK: Indeed.

CONAN: Dr. DuPont, are you agreeing?

DUPONT: Well, I think it's - this is such a polarizing issue that gets such extreme positions, and to put two doctors here who have an awful lot of overlap in their interest, including being psychiatrists, I think is very unusual and I think very positive.

Let's start off, though, Neal. You talked about prescribing. You can't prescribe marijuana anywhere. Doctors recommend it. It's not a medicine that you can prescribe anywhere. So the issue is recommendation. And what we're talking about with Dr. Bostwick is a thoughtful consideration of a physician who's got an ongoing relationship with a patient when the patient's got a lot of problems after having tried a lot of other medications.

That's not what medical marijuana is about in this country. Ninety percent-plus of the marijuana recommendations are sold by doctors who virtually the only thing they're doing is putting out those recommendations.

CONAN: And is too fine a point to call that corruption?

DUPONT: It's a kind of de facto legalization.

CONAN: But using the agency of a doctor.

DUPONT: Well, the doctor sells the agency for a year. The marijuana certificate is good for a year. It typically costs about $200. It takes about 15 minutes to do that, and you're part of a mill going through, and it's advertised on billboards. Nothing - and when you get the certificate, you go to a dispensary, and you pick out how much you want, of which thing, and it's a discussion that bears no relationship to medicine anywhere in the country. That's what medical marijuana is as it's going on in the country today.

CONAN: But Dr. Bostwick, yes, there is that, and that's hard to deny, and when you see signs, neon signs, it's a little difficult to equate that with medicine, yet there are oncology patients and others who benefit from marijuana.

BOSTWICK: Well, one of the challenges here is that marijuana has been used medicinally for 5,000 years, and including in the U.S. for 100 years legally. And the illegal, the Schedule One designation of marijuana, which made it illegal, was actually a political decision as well, not supported by science, because the science hadn't yet been done.

CONAN: Schedule One, of course, is federal law, but go ahead.

BOSTWICK: Right, federal law, but the effect of being a Schedule One drug is that it's very difficult to do research on that drug. And one of the contentions I would make is that we have many other examples of drugs of abuse that also have closely related medicinal compounds that are Schedule Two or Three, which means you have to be careful when you prescribe, but they are not completely forbidden.

And I do think there's enough literature, much of it anecdotal, to support that marijuana is not completely without any kind of benefit. That being said, Dr. DuPont's description of particularly the situation in Colorado is very accurate and quite crazy.

(LAUGHTER)

DUPONT: You were talking about the history about this, and let me just add to that, marijuana was used historically, but by the 1930s it was virtually abandoned. It was still legally prescribable, but nobody prescribed it. It had vanished from any kind of use at all. So by the time the Controlled Substances Act came in 1970, this medical use was ancient history.

Now, Dr. Bostwick was talking about history. I became the director of the National Institute on Drug Abuse in 1973, and one of the first things we did was look at marijuana and THC, the chemicals in marijuana, and medical uses. So the publications from the National Institute on Drug Abuse began in the early 1970s about this, and every single review, scientific review, has come to the exact same conclusion that the Institute of Medicine did in 1999, and that is the medically interesting issue is the individual chemicals in marijuana, not the plant itself.

There is no future to that. You don't have medicines that are taken by smoking. This is not - this is not medicine. The Food and Drug Administration doesn't approve plants. They approve specific products that have purity, safety and efficacy. There's no possibility of doing that with this.

CONAN: You say there's no future in it. Tell the voters in 18 states.

DUPONT: Well, that's what I expect Eric Holder to do. And we'll see what happens with that. But I think the point is that look at what's happened to morphine. Morphine came from opium when it was purified. And it wasn't only that morphine became used as a purified chemical, but the synthetic analogs were developed. That is exactly the future of cannabis.

And the reason it's so interesting is I'm in favor of that, and the people who are supporting medical marijuana are against it because all they want is smoke dope.

CONAN: A quick response, Dr. Bostwick, and then we'll get a caller in.

BOSTWICK: Yeah, I don't - there actually are medications that are absorbed through the lungs and absorbed through the mouth. They're not smoked; they're used with vaporizers or with inhalers. Part of the issue with our current state of medical marijuana - or marijuana used appropriately is that we do not have a way of delivering it quickly.

CONAN: Let's get a caller in. We want to hear from doctors today. What kind of conversations do you have with your patients? What's your thought process when the issue of medical marijuana comes up? 800-989-8255. Email talk@npr.org. Stephanie's on the line with us from Santa Jose.

STEPHANIE: Yeah, hi. I'm an internal medicine physician. I graduated in 2001, took my boards and started off being a general internist and doing pain control for a neurosurgeon. He did it for workers comp, et cetera, and with people with chronic pain that exhausted all options for surgery. Went on to be a hospitalist for 10 years and did increasing training in the ICU and as a hospitalist admitting patients, covering between 12 and 15 patients a day and prescribing them all sorts of things that just led to one thing after another after another as far as side effects.

Now as a primary care physician in an inner-city clinic, basically it's one of the main things that patients really, really benefit from. And there are things that we screen for first. First of all, of course pregnant women can't take it. And you don't do an active psychiatric patient. You have to have extensive clearance from their psychiatrist. And you follow up with them on a regular basis. You don't just give it for 12 months, bye, see you.

Those people give us a really, really bad name as far as any kind of medicine is concerned. We are physicians, and this is an active compound, THC, that's actually found in marinol. In marinol, unfortunately, it only has THC in it, and it is a pill that's prohibitively expensive for most of my patients. I see mostly inner-city and very poor patients.

And this is something that helps them and replaces a lot of those medications that they would be prescribed with MediCal and with other, you know, prescription plans.

CONAN: So in some cases some of the time and carefully monitored, yet as you say, your industry gets a bad name - well, it's not your industry, the practice...

STEPHANIE: Oh, yes. I mean it gets a bad name with several people when - and I would say $200 is on the high end. In many cases I waive the fee completely. Someone comes in, most of my patients they come in with a wheelchair. I've seen 104-year-old patients that come in. Most of my patients actually are professionals, are people with, you know, physicians who don't want to talk about it.

You know, I have lot of patients who are Kaiser patients, for instance, and Kaiser cannot prescribe it to them because they receive federal money. So if they receive federal money, then they cannot go and actually give a recommendation. I think recently Kaiser started to do it. The VA just has been sending me a lot of patients themselves. They can't say that they will, but a lot of the PTSD patients that are coming back from Iraq and Afghanistan, I mean they're, you know, what we used to call shell-shocked. Finally they're coming to terms with it, and they're coming in.

And instead of waking up in the middle of the night with night sweats and choking their wives, et cetera - I could name tons of examples - they basically vaporize, I would never encourage smoking, but vaporize or do a tincture or do a tiny bit of a very well-dosed edible and then go to sleep, period.

CONAN: And it's interesting, Dr. Bostwick, what Stephanie's telling us, even in cases where she's clearly thoughtful and careful with this, there's a wink-wink, nudge-nudge, and it's all under the table, and people are - you know, it's all pretending.

DUPONT: Well, indeed it is, but that's the problem. When you have 18 states that have - are in violation of federal law or at least in distinction to it, that's a major problem. When you have a drug that does in fact have reason to be studied, and you make it completely unable to be studied, then we can't get out of this bind that we're in.

Some have argued that simply making it a Schedule Two drug, so it could be watched carefully but studied, would solve the problem. So I mean I think that the craziness going on, I mean the notion that the VA, a federally funded institution, would be sending patients on the sly to a provider because they give good results speaks to the craziness of the situation that we're in.

CONAN: Stephanie, thanks very much for the phone call.

STEPHANIE: OK, thank you for taking it. Thank you.

CONAN: We're talking with doctors about how they make decisions on prescribing pot or recommending pot. If medical marijuana is legal where you practice, how do you decide whether or not to recommend it? 800-989-8255. Email talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(SOUNDBITE OF MUSIC)

CONAN: This is TALK OF THE NATION from NPR News; I'm Neal Conan. As more states legalize medical marijuana, doctors face decisions. Do you recommend pot to your patients or not? Doctors, we want to hear from you today. If medical marijuana is legal where you practice, how do you decide whether or not to recommend it? Give us a call, 800-989-8255. Email talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Two doctors are with us. Dr. Robert DuPont serves as clinical professor of psychiatry at Georgetown University Medical School. He previously served at director of the National Institute of Drug Abuse. Also with us, Dr. Michael Bostwick, professor of psychiatry at the Mayo Medical School and consultant to the Department of Psychiatry and Psychology at the Mayo Clinic. And let's see if we can get Eric(ph) on the line, Eric's on the line with us from Phoenix.

ERIC: Hey, good morning, Neal.

CONAN: Good morning, go ahead.

ERIC: OK, so my main point was on the efficacy claims brought up by your two guests. I used to work in the preclinical toxicology field studying mostly early safety assessments for the pharmaceutical industry. And in that position I saw the USDA and the FDA coming in with very strict guidelines that were easily circumvented by study procedures.

After spending three to four years in that field and working closely with that, I quickly noticed that there was false efficacy claims by most pharmaceutical companies in their early preclinical stages. That is a huge cause for concern for anybody taking anything out there, as far as Tylenol all the way up to any of your prescription anti-cancer, antineoplastic drugs is what they're called.

CONAN: And how does that relate to medical marijuana?

ERIC: Well, when you look at the human body evolutionarily speaking, we've got endocannabinoid receptions and exocannabinoid that we call phytocannabinoid derived from plants. And when you look at the human body, we've noticed that runners on long-distance runs, they actually produce a cannabinoid that binds to that receptor and causes the same euphoria that you would get from THC.

The more important point here is that THC is not the important thing. The important thing is the synergistic effect of THC coupled with CBD, CBN and CBG.

CONAN: These are the compounds within the plant.

ERIC: Exactly. These are supporting roles, if you will, for cannabinoid research. And what's being found more and more is that CBD in reference - or I'm sorry in ratio...

CONAN: Wait, everybody's citing studies, and I'm not sure what's - we can validate any of that. But how do you know, Eric, what the potency of any particular amount of marijuana is? What's a dose? What's a proper dose? Why is one batch similar to another? These are problems, aren't they?

ERIC: Absolutely, absolutely, and as the industry grows, and as more and more people become educated in what to look for and what a true good medicine is and how it is grown, science has showed us throughout the ages that scientific procedure is very, very important when it comes to repeatability, and repeatability with medical marijuana is key. The only way to find that repeatability to where you are consistently producing a product with the same levels, or the effective levels, is through true scientific research and propagation.

So with my studies, we grow and produce a very repeatable level of THC to CBD to CBN to CBG. And that's where it's at. If you can normalize your results, you can start on a road to true knowledge, and as we all know, knowledge is power.

CONAN: All right, Dr. Bostwick, I'm not sure how many physicians are in Eric's position in the ability to conduct those kinds of studies.

BOSTWICK: Well, I'll just toss something else into the mix. Even as we demonize smoking marijuana, the patient decides what the right dose is for the effect that they want. So it is certainly true that there are all different kinds of marijuana with all different kinds of ratios of THC to CBD, et cetera, but the patient is actually making some decisions, and one of the advantages of a vaporized or a smoked preparation is that you get an instant response, and you can back off as quickly.

DUPONT: Well, to me the question Eric was talking about of ratios of particular cannabinoids, there are 80 unique chemicals in marijuana - are called cannabinoids, and he's talking about four of them. If there was some ratio, you would do that as a medicine to lock those in the way you wanted to have them, and you would have a product.

Now let's just think about this. The FDA does not approve chemicals. They don't approve a mixture of chemicals. They approve a particular product. And the product has got to be pure. It's got to be consistent every time. To think about what you're going to do to approve a medicine that you're going to get in a pharmacy that is going to have a certain ratio of cannabinoids, unless you're going to have the whole industry go to Eric for everything he wants, that's impossible. You're going to have to have...

BOSTWICK: Well, the Sativex...

CONAN: One at a time, Go ahead, Dr. Bostwick.

BOSTWICK: The Sativex that's currently in phase three trials actually contains ratio of TCH to CBD, and there are variable ratios with several different preparations of it. So yes, that makes total sense. And certainly we know that drug dealers going only for a high will try to get rid of the CBD. So I'm not disagreeing with that at all.

But I am saying that in the absence of these compounds that we're talking about, theoretically, patients do titrate the medication to effect.

DUPONT: Dr. Bostwick, one of the points you made that I want to from my point of view correct or at least put a different point of view in, is schedule one does not prohibit, or even inhibit in a significant way, research. Marijuana has been researched by the National Institute of Drug Abuse for nearly 40 years. And there's plenty of research going on about that.

The issue really has to do with how do you - when you're doing the research, how do you justify studying a plant as opposed to studying the specific chemicals. I think that's a very difficult problem. But it is possible to do it, and the National Institute of Drug Abuse, in that 40 years, has produced marijuana to give to researchers so they can do studies of marijuana.

So it's not that the government is stopping that, that is not a problem.

CONAN: Dr. Bostwick, other people would disagree with that.

BOSTWICK: Yeah, I would actually very much so disagree with that. Because of the network of agencies that weigh in on this, it's been extremely difficult for researchers to get the federal marijuana. It's interesting that the program opened with a quote from Dr. Abram, who from what I've read has tried repeatedly to do studies and been repeatedly thwarted.

DUPONT: But it's not because it's schedule one. If it was schedule two, he'd be thwarted the same way, because he's not meeting the scientific standards.

CONAN: Let's get another caller in on the conversation. Jeremy(ph) is with us from Fort Collins in Colorado.

JEREMY: Hi, how are you doing today?

CONAN: Good, thanks.

JEREMY: I'm a family physician up here in Fort Collins. I'm also an addiction medicine specialist. And, you know, it's interesting that we get patients very often, especially from the addiction circles, that you can get addicted to anything, whether it's booze, marijuana, Vicodin, heroin, you name it. And marijuana is no exception with that. It can destroy your life just like anything else.

But - and I'm not someone that actually signs off on those applications that often. But as a family physician, you know, we're faced with a certain reality here, and this is what we try to teach the medical students and residents that we get, too, is that there's some sort of screening that needs to occur even as we have this unknown with medical marijuana, and of course to make sure that they don't have co-occurring mental health diagnoses, that you have been seen by a psychiatrist or that you have some sort of survey of that, as well as that these folks come in, and they have chronic pain.

And often what happens is that you see, and not all the time, but you see in about a 10 to 15 percent statistically this population of people that are taking drugs, that although studied, have higher side effect profiles. For instance, our opiates out there. And we prescribe opiates often. But for instance when you're making comparisons, someone who comes in and says to you, and often this happens even illicitly, where they come in and say, you know what, I tried a tincture and some friend's house, and now I haven't taken my Oxycodone or my Vicodin for a month, how do you respond to that as a family physician.

And so the idea that we try to include education and explain to these people look, there's a federal law against this, and there's - and we don't have a lot of research, and NIDA has done a really good job at doing some of this research. There's also an institute in Holland that has, too, as well as something in California.

We need more research, we need more education, but we have to be honest with the realities on the ground here. People are doing this anyway, and we can - and I'm not saying that we should condone it, and as someone who doesn't even prescribe it and is very sensitive to the potential substance abuse with it, as a family physician, there's the realities out there of what do we do to help these people.

And some of these people are coming in and saying, you know, I'm off much harder interventions, and I'm now using this. And of course we don't recommend smoking, but I'm using this intervention now, and it's something that might be a lower-risk profile, and I still think there's some research that needs to be done.

CONAN: Dr. Bostwick, some cases, some of the time.

BOSTWICK: I would certainly agree with that, yes. But again what I'm hearing from the caller, the people who are calling in, is that they're doing this in the context of a careful relationship and a lot of thought and in fact an awareness of the fact they're caught in a dilemma between state and federal law. It would be interesting, I think, if one of the Colorado marijuana pushers called in, but they're obviously not going to do that.

DUPONT: Well, two states have legalized marijuana: Washington and Colorado.

CONAN: They're still working out procedures. So...

DUPONT: Well, but it's very interesting, because the medical marijuana people are against that, because once they're legalized...

CONAN: Some are and some aren't.

DUPONT: ...it's gone, and the game is over.

CONAN: Yeah. Thank you very much, Jeremy, for the phone call.

JEREMY: Thank you.

CONAN: Let's see if we can go next to - if I can push the button properly - let's see if we can go next to Paul, and Paul's on the line with us from Denver.

PAUL: Yes. I'm a cannabis expert and a physician here in Denver, and I take issue with the gentleman who talks about pot pushers and things like that, because I have evaluated patients in the past, thousands, and they are basically desperate. Eighty to 90 percent of these people have been in pain and have been given multiple pain medicines, and 25 percent were addicted.

And you have to look at the patient, as a whole, who's coming in and saying, OK. I don't have the psychological problems, but I'm trying to deal with my pain, and I'm trying to deal with sleep, et cetera, et cetera. And this works for me, and they're grateful to be able to get the recommendation.

Now, do all the people - are some of the people using it for recreation? Of course they are. But in the big scheme of things, there's never been a reported death from cannabis use, as opposed to, what, 200,000 deaths from prescription medicine and 20,000 deaths from opiates? So that has to be dealt with.

When you have people like Dr. Donald Abrams talking about this and other smart doctors doing this, you have to look at the whole big scheme of things within medicine and see the desperation that people are trying other - need to try other medicines.

This is a medicine that does work, and this is a medicine with minimal side effects. And what's coming is CBD plants that are going to be grown that are going to not get people high, but yet are going to be therapeutic. So - and it's going to mimic what's going on in Israel. Do we need more research? Yes. Are there - are we up against some big lobbying efforts? Yes.

But there are so many other ways. You have topicals, you have tinctures, you have edibles that you can control. The science of cannabis is changing radically. And still, inhalation, you can take titrate. We don't believe in this country on the fact that the patient may be able to titrate themselves. It's all about what the doctor has to do and the controls that have to be done and things like that.

So I just came back from a conference that was in Washington, D.C., and bills are being introduced to help this industry and medicine move along. So as the doctor there talks about pushing this medicine onto people, yes, it shouldn't be for teenagers, and it shouldn't be for people who are prone to psychological damage and things like that.

But in the big scheme of things, when you look at the qualifying conditions here in Colorado, and you have pain and you have seizures and you have spasms and you have nausea and you have side effects of other medicines, and people are telling you - and are so grateful that they can get this medicine, you - you're in a position where I feel very grateful to have helped them.

CONAN: We're talking about medical marijuana and the decisions doctors have to make about recommending it to their patients. You're listening to TALK OF THE NATION, from NPR News.

Dr. DuPont?

DUPONT: Are we on?

CONAN: Yes.

DUPONT: Oh. I just want to say the future is in the specific chemicals, and there's no question about that, and likely going to be not grown in a plant, but synthetic analogs of those. And I am all in favor of that. I think that is the right thing.

The problem, though, is that the issue has to do with the marijuana plant and smoking it. And that's what the debate is about, not about the future of the use of those chemicals to treat all kinds of conditions.

CONAN: And, Dr. Bostwick, I think Paul was referring to some of the remarks you made about...

BOSTWICK: Yeah. I should clarify. I mean, I'm obviously not from Colorado. I'm in Minnesota, which doesn't even allow us to prescribe. But I'm referencing an article by Nussbaum in the Journal of General Internal Medicine that pointed out that there were a handful of doctors prescribing most - a larger portion of the marijuana in the state, having seen the patient only once and never again.

So - in that case, that totally takes the relationship out of the picture. It also takes the follow-up out of the picture. It takes any kind of what I consider to be responsible medical practice out of the picture.

And, again, I would add to Dr. DuPont's remarks that the question is how we get from smoked marijuana to these refined chemicals as quickly as possible. And that does not necessarily, for my awareness, seem to be happening very quickly

For example, nabiximols is still in stage-three trials, well into 2014. That's a year from now. What do we have to learn? It's legal in Canada, and apparently works very well, and has been for six years.

CONAN: Paul, thanks very much for the phone call. Appreciate it.

PAUL: Lung cancer, et cetera, et cetera. There may be bronchitis and things like that, but as far any incidence of cancer, causation has not been proven. And, in fact, with its antioxidant effect, you've seen the fact that cancer rates in some cannabis studies have gone down.

CONAN: Again, some studies...

DUPONT: The FDA doesn't go with some studies, or some studies - it has a very formal process. And I think, Neal, the idea that we're going to approve medicines by ballot initiative is a dangerous precedent in this country. We've worked hard to get a science-based approval process for our pharmaceuticals, and we need to defend that. And this is an end-run around that that is very dangerous, not just for the marijuana, but for the precedent it sets for other drugs.

CONAN: So given that, would you say a recommendation of marijuana in any circumstance is malpractice?

DUPONT: No. I think the physician is dealing with - and Dr. Bostwick presents it in a very good way. There's a different issue about what happens with a physician talking to a patient when he's got a relationship and is doing everything possible he or she can do to help that patient.

And I'll point out to you that even in the states where there is no legal medical marijuana, there's very few people there who can't get marijuana. This is not a problem that is limited to a - a product that's limited to do a pharmacy. And I think the discussion goes on in those states just the same way.

CONAN: Whether you think it's appropriate or not, people are using it for medicine.

DUPONT: Well, I'm not saying that every time a doctor does that, it's a wrong thing, either. What I'm talking about is this idea that presenting it as a medicine that the doctor is going to prescribe and that we need to have that approved out in the country as a medical treatment, I think that's a big mistake. What happens between a doctor and the patient, that's an entirely separate thing and a sacred thing, as far as I'm concerned, around the issue of working with that patient.

CONAN: All right. And I'm afraid we're going to have to leave it there. But Dr. Robert DuPont, thank you very much for your time today.

DUPONT: Thank you.

CONAN: Dr. DuPont is a clinical professor of psychiatry at Georgetown Medical School, former director of the National Institute of Drug Abuse. Our thanks as well to Dr. Michael Bostwick, who was with us from the Mayo Clinic in Rochester, Minnesota. Appreciate your time today.

BOSTWICK: Thanks so much.

CONAN: Dr. Bostwick, professor of psychiatry there at the Mayo Medical School. Coming up after a short break, we're going to be talking with Tom Friedman - the columnist for The New York Times - on the political realities of the Keystone XL pipeline. Cue up the protest, he says. I'm Neal Conan. Stay with us. It's the TALK OF THE NATION, from NPR News. Transcript provided by NPR, Copyright NPR.